Provider Demographics
NPI:1376851410
Name:FULLER, CHERYL A (APN)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:A
Last Name:FULLER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277
Mailing Address - Street 2:
Mailing Address - City:DONGOLA
Mailing Address - State:IL
Mailing Address - Zip Code:62926-0277
Mailing Address - Country:US
Mailing Address - Phone:618-827-3545
Mailing Address - Fax:618-827-4891
Practice Address - Street 1:318 US HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:DONGOLA
Practice Address - State:IL
Practice Address - Zip Code:62926-1103
Practice Address - Country:US
Practice Address - Phone:618-827-3545
Practice Address - Fax:618-827-4891
Is Sole Proprietor?:No
Enumeration Date:2010-09-23
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008363363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily